OTA Patient Mental Health Grant Program Application

OTA Patient Mental Health Grant Program Application
Personal information
Name

First Name Last Name
Job Title
Email
example@example.com
Phone number
Please enter a valid phone number.
Please upload your CV

Institutional information
Name of institution
Department
Institution Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name of institution officer responsible for grant

First Name Last Name
Institution officer job title
Institution officer email
example@example.com
Institution officer phone number
Please enter a valid phone number.

Program information
Program title
Please summarize the proposed program and anticipated impact (200 words)
Why is this program warranted? (300 words)
Program description and implementation strategy (500 words)
Measurements of outcome and effectiveness (500 words)
Institutional impact (200 words)
Institutional support (present and anticipated; 200 words)
Future directions for this work (200 words)
Program timeline
Please attach letters of support from Chief Operating Officer, Director of Trauma, and Director of Orthopaedic Trauma

Please outline your proposed budget below, including the following:
NO indirect costs are permitted.

SALARIES AND WAGES
(List all personnel for whom money is requested)
- % effort on project
- Requested from OTA (round to $)
- Fringe Benefits _______% of Salaries and Wages
- Total of above
PERMANENT EQUIPMENT (include justification)
- Estimated cost
CONSUMABLE SUPPLIES
- Estimated cost
ALL OTHER EXPENSES
- Estimated cost
TOTAL DIRECT COSTS _________________
Estimated budget
Should be Empty: